Breast Cancer 2 - Diagnosis & Staging

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In our last article, we talked about the standards and recommendations for breast cancer screening, which covered imaging techniques and breast cancer risk factors.

These screening tests are mainly to identify if there’s anything suspicious going on in the breast or surrounding tissue that could indicate the presence of cancer.

This is helpful for catching cancer as early as possible in the hopes that treatment can be less invasive and more effective.

This time, we’re going to look at what happens if screening tests come back positive?

If a screening test comes back with an abnormality or something to make your doctor suspect cancer, it goes into the diagnostic and staging phase.

The basic steps during this phase include:

  • Identify if it’s cancer

  • Classify the cancer

  • Stage the cancer

It’s important to understand that suspicious doesn’t mean cancerous. Your doctor will need more than a positive result on a single mammogram to understand what’s going on and how best to proceed.

Identifying Suspicious Results from Screening

There are several things that your doctor may view as suspicious on mammogram.

Common things that you may hear your doctor talk about are:

  • Spiculated: On a mammogram, breast tumors will most likely appear as a spiculated soft tissue mass. (Spiculated means that the mass has spikes or points extending into the surrounding tissue).  

  • Microcalcification: Many breast cancers present with microcalcifications located around the tumor. Microcalcifications are calcium deposits that occur around a tumor indicating areas of necrosis (cell death).

  • Multifocal or multicentric: If multiple tumors are found within the same quadrant of a breast this is known as multifocal disease. If multiple tumors are found in different quadrants of the same breast this is known as multicentric disease.

When mammography indicates something suspicious, your doctor may utilize adjunctive imaging to get a better ‘picture’ of the mass.

Examples of common adjunctive imaging include:

  • Ultrasound: Beneficial in cases where a person has dense breast tissue that interferes with mammography. In such cases, a mammogram may not be able to fully view a lesion.

    Ultrasounds can also be used to distinguish solid lesions from cystic masses and to view axillary lymph nodes to see if there are any abnormal lymph nodes which could indicate a potential of cancer.

  • Breast MRI: May also be utilized to look for additional lesions in both breasts. Although breast MRI is sensitive in displaying the structure of the breast to the physician, they are not specific and may lead to false positive results.

Any abnormality on a mammogram is enough to cause a person some distress. Further, many of the testing procedures after the initial discovery of abnormalities carry some additional degree of risk to the individual being tested.

That being said, one of the goals your medical team will have is to minimize the amount of imaging and procedures that a person needs to undergo while at the same time getting a clear understanding of what those abnormalities mean.

To do this, radiologists summarize mammograms using a process called the BI-RADS system (Breast Imaging Reporting and Data System).

This system uses categories from 1-6 with 1 being negative and 5 being highly suggestive of a cancerous lesion. (Category six is for a lesion that has been biopsied and is a proven malignancy). Using the BI-RADS system, your physician is able to monitor breast abnormalities to the degree deemed medically appropriate to balance patient welfare with appropriate surveillance of the abnormality itself.

Because of the balance of decision that’s required to do this correctly, it is important to work with an integrative multi-disciplinary team of medical professionals that are highly experienced in the treatment of breast cancer.

In some cases, even when a mammogram comes back negative, or inconclusive, your doctor may recommend something called a biopsy if there’s any clinically suspicious mass because mammography (like many things) isn’t 100% accurate and may miss up to 15% of breast lesions (1)


Biopsy & Diagnosis

A biopsy is the only way to know for certain whether or not a suspicious area is cancerous.

Depending on various factors, such as whether a lesion is palpable and what imaging is best suited to view it,  there are multiple different types of biopsies that can be performed. The type of biopsy needed will be decided by your care team based on current medical standards as well as your individual circumstances.

Most biopsies listed below can be done under local anesthesia while you are awake.

Your doctor will likely inform you of certain risks or effects that biopsies may carry, such as bruising and inflammation in the breast or enlarged axillary lymph nodes.

There is some concern over whether biopsies can spread tumors along the insertion site (1). However, research in this area indicates that despite the potential concerns, biopsies are safe overall and the pros outweigh the cons.

Keep in mind that any concerns you have can and should be discussed with your physician.

Types of biopsies for breast cancer include: 

Punch biopsy: A punch biopsy uses a hollow tube-shaped device to take a core shaped tissue sample of the skin. It is used to on lesions of the skin such as Paget’s disease of the breast, inflammatory breast cancer, or invasive cancer that has skin involvement. 

Fine needle aspiration (FNA): In this type of biopsy, a needle attached to a syringe is inserted into the tumor tissue and tissue and or fluid is drawn up into the syringe.

This type of biopsy is commonly performed if a tumor is fluid filled, if it is easily accessible, or if the suspicious tissue is a lymph node. A fine needle aspiration biopsy can be guided by palpation or by ultrasound.

These kind of biopsies are quick and easy to perform, may be performed during imaging, and give results quickly.

The downsides of FNA are that they cannot be used to distinguish between infiltrative and in situ carcinomas, and efficacy can vary based on clinician experience 

Core needle biopsy: This type of biopsy is done under local anesthesia. An incision is made in the skin and a larger gauge needle is used to take a sample of the tumor.

Like a punch biopsy, a large core of tissue is removed from the tumor.

This procedure can be guided with the imaging modality that best visualized the lesion such as ultrasound, mammogram, tomosynthesis.

A stereotactic biopsy is one done on a special table where a mammography is used as the imaging modality during the biopsy.

During biopsy, the surgeon may leave something called a clip at the site of the biopsy. This is a metal marker at the site of your lesion that helps show where the lesion is (or was) during follow up. 

Surgical biopsy:  A surgical biopsy is performed less often than a core needle biopsy for initial diagnosis. It is also done under local anesthesia and should be performed in a hospital setting.

The surgeon may either remove a part of the tumor, called an incisional biopsy, or the entire tumor called an excisional biopsy.

In the case of an excisional biopsy, the surgeon usually removes some additional tissue surrounding the mass, known as a margin, to ensure cancer did not further extend into surrounding tissue.

A surgical biopsy is usually performed if a core needle biopsy is unable to be performed, if there are suspicious changes after a core needle biopsy, or if a cyst does not resolve after aspiration.

Similar to a clip used in a core needle biopsy, a wire may be placed in the breast with the assistance of imaging prior to surgical excision to indicate the area of the tumor to the surgeon.

Reasons for a surgical biopsy include complete removal of a tumor (which we’ll talk about in an upcoming article), to histologically diagnosis a patient, and to completely remove/ evaluate lesions/ areas of suspicion such as DCIS and calcifications. 

Imaging is usually performed on the sample after it has been removed to confirm that the entire lesion has been removed. It is also used to determine if there is a clear margin, or if the surgeon has to go back and take more tissue.  

 

Breast Cancer Classification

Once a biopsy is taken a breast cancer diagnosis may seem straightforward.

However, there are multiple aspects involved in determining the type of breast cancer and its specific characteristics. These include the cancer’s:

  • Histopathology

  • Grading

  • Molecular characteristics

  • Genetic characteristics

Histopathology of Breast Cancer

To start, the biopsied tissue is sent to pathology where it is examined under a microscope. 

There are different types of breast cancer. Which type a person is diagnosed with depends on which tissue the breast tumor initially formed in. This means that several people who all have ‘breast cancer’ could have disease that differs both in appearance, as well how it responds to treatment.

Common types of breast cancer are:

  • Invasive ductal carcinoma: This is the most common type of breast cancer and accounts for 70-80% of all invasive lesions of the breast. This cancer originates in the milk ducts, hence ductal, but has invaded into the surrounding tissues. 

  • Invasive lobular carcinoma: This form of cancer constitutes 8% of all breast cancers (3). It originates in the milk lobules of the breast and is typically more-slow growing than invasive ductal carcinoma.

  • Mixed ductal/ lobular carcinoma: This tumor type constitutes around 7% of all breast cancer and contains both lobular and ductal components (3).

  • Mucinous, tubular, medullary and papillary:  These are other types of breast cancer that constitute around 5-6% of breast cancer (3).

  • Carcinoma in situ (CIS):  This condition is considered a pre-cancerous lesion or non-invasive stage 0 cancer. Ductal carcinoma in situ (DCIS) occurs when abnormal epithelial cells in the milk ducts replicate and line the duct. However, these cells have not invaded into surrounding tissue.

    In situ means “in place” which indicates that these cells stay in their place.

    The same can occur in breast lobules and this is known as lobular carcinoma in situ (LCIS). This is much less common than DCIS. 

  • Inflammatory breast cancer:  Inflammatory breast cancer is a rapidly growing, rare, and aggressive form of breast cancer. It presents with pain and or a rapidly growing breast lump. Typically, the skin of the breast may look like it has a rash and is warm, thickened and itchy. The breast may also look swollen as inflammatory breast cancer usually involves the lymph nodes and, in many instances, has metastasized to other locations. Furthermore, the nipple may look abnormal and be retracted, crusted or flattened. 

  • Paget’s disease of the nipple:  presents as an ulceration or eczema-like rash on the nipple and areola. It may also have present with copious yellow or bloody discharge from the nipple. This disease may be isolated to the nipple, but it also may be a sign of an underlying breast tumor. 


Breast Cancer Grading
 

Grading tells us what your cells look like under a microscope. It is used to give an idea of how quickly cancer cells are growing, which in turn predicts their ability to spread.

Invasive forms of breast cancer are assigned a grade based on a numeric system from 1-3. Non-invasive types of cancers, such as ductal carcinoma in situ (DCIS), use a rating of low, medium, or high-grade, instead of 1, 2, or 3.

Grade 1 cells are small and uniform and closely resemble normal cells. On the other hand, grade 3 cells are large, non-uniform, and generally replicate quickly.  


Molecular Characteristics 

After a breast lesion has been biopsied it will be sent for molecular testing.

The cancerous cells will be tested for the presence of estrogen receptors, progesterone receptors, and for human epidermal growth factor receptor 2 (HER2).

When cells have upregulated estrogen receptors as well as progesterone receptors this means that estrogens and progesterone in the body can bind to these cells causing them to grow.

Overall breast tumors that are hormone receptor positive have a favorable prognosis because there are therapeutics that can block these receptors which, in effect, limits cancer cell growth.

HER2 is a gene that when upregulated leads to increased cancerous growth. It is estimated that some 30% of breast cancers are HER2 positive (HER2+). There are therapeutics that have been developed that can block HER2 expression which has greatly improved outcomes for patients that are HER2+.

If a tumor doesn’t express estrogen receptors, progesterone receptors, or HER2, it’s considered to be triple-negative. This type of breast cancer is usually considered harder to treat since there are limited receptors to target, and a combination of chemotherapies usually has to be used. 

Genetic Testing

Another step that your doctor might recommend is genetic testing.

If you have a genetic mutation such as BRCA1 or 2 this may change the recommendations for your treatment regimen. It could also impact how often you follow up or are screened by your physician. These genetic mutations may change the age at which it is recommended for your family members to start being screened.  

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Genetic testing is helpful in finding out which mutations may lead to breast cancer. You may have heard of the BRCA1 and 2 mutations. However, there are many mutations such as CHEK2, PALB2, PTEN, TP53, ATM and many others that have been implicated in the development of breast cancer as well as other cancers such as ovarian cancer.

Your doctor may recommend you have genetic testing done if you have a family history of breast cancer.

Currently, there are limited therapeutic options to target these mutations, but as discussed in our last blog post, if you are a carrier of one of these mutations, it may affect the age that your doctor would suggest you begin routine breast cancer screening with mammography.

If you are worried that you may carry a genetic mutation that puts you at risk of developing breast cancer, we recommend you speak to a genetic counselor instead of buying an online test kit.

These individuals are trained to assess your risk and determine whether you need testing. If you do decide you would benefit from it, they can also help you to understand your results and discuss potential treatment options with you. 

 

Breast Cancer Staging

Staging is a system which helps to determine the size of a tumor and how far it has spread throughout the body.

The ‘TNM system’ is used for staging. TNM stands for:

  • Tumor: Where is the tumor located, and how large is the tumor?

  • Node: Is there cancer in the lymph nodes? If so, which ones, and how many?

  • Metastasis: Has the cancer spread to other parts of the body? Where has it spread to? 

This information is combined to determine what ‘stage’ of breast cancer a person has, which in turn helps to direct treatment decisions.

In general, stages 1-3 describe disease that is confined locally to the chest whereas stage 4 indicates cancer that has metastasized to other areas of the body. Stage I through 2A is considered early stage whereas 2B through 3 is considered locally advanced. 

  • Stage 0 (Tis, N0, M0): As previously mentioned, DCIS or LCIS is considered stage 0. These are confined to the ducts or lobules and have not invaded into surrounding tissue. 

  • Stage IA (T1, N0, M0): The tumor is small (1-20 mm), invades surrounding tissue, but has not spread to the lymph nodes or other areas of the body. 

  • Stage IB (T0 or T1, N1mi, M0): The tumor in the breast is 20 mm or smaller, or there is no tumor in the breast. There is cancer in the axillary lymph nodes that is at least 0.2 mm but smaller than 2 mm, which is known as micro-metastases. 

  • Stage 2A:  (Can fall under any one of these conditions). 

    • (T0, N1, M0) Cancer is found in 1-3 axillary lymph nodes but cannot be found in the breast or in distant parts of the body. 

    • (T1, N1, M0) The tumor found in the breast is less than 20 mm and has spread to 1-3 axillary lymph nodes. 

    • (T2, N0, M0) The tumor is larger than 20 mm but smaller than 50 mm and has not spread to the axillary lymph nodes. 

  • Stage 2B: (Can fall under any one of these conditions).

    • (T2, N1, M0) The tumor is larger than 20 mm but smaller than 50 mm and has spread to 1 to 3 axillary lymph nodes. 

    • (T3, N0, M0) The tumor is larger than 50 mm but has not spread to the axillary lymph nodes. 

  • Stage 3A: (T0-T3, N2, M0) or (T3, N1, M0): Cancer (of any size) which has also spread to 4-9 axillary lymph nodes or to internal mammary lymph nodes. It has not spread to other parts of the body. Alternately, it may also be a tumor larger than 50 mm that also has small areas of cancer in the lymph nodes.

  • Stage 3B:  (T4; N0, N1 or N2; M0): The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the axillary or internal mammary lymph nodes, but it has not spread to other parts of the body.

  • Stage 3C: (any T, N3, M0): A tumor of any size that has spread to 10 or more axillary lymph nodes, the internal mammary lymph nodes, and/or the lymph nodes under the collarbone. It has not spread to other parts of the body.

  • Stage 4: (any T, any N, M1): The tumor can be any size and has spread to other organs.

Breast Cancer Survival Rates

After any cancer diagnosis, people want to know what their chances are of beating it or surviving in their diagnosis.

Doctors often respond to those questions with statistics referencing something called ‘survival rates’.

Survival rates are used to tell us how many people, after diagnosis with a similar type and stage of cancer, are still living after a specific amount of time (usually 5 years).

What this means is that if a specific type of cancer has a 90% five-year survival rate then 90 out of 100 individuals with that cancer are alive 5 years after diagnosis.

It’s important to keep in mind that these numbers are averages and are influenced by numerous factors.

Many individuals surpass these numbers and many have lived much longer than they were ‘predicted to’ using survival rates as their method of comparison.

Another way to look at survival is by comparing relative risk. Studies that do this look at the survival of individuals diagnosed with cancer in comparison to healthy people that are a similar age, race, and sex. This better narrows the comparison of the effect and likelihood a specific cancer diagnosis may have on an individual.

Obviously, there may be differences in outcome if two people have the same type, grade, and stage of cancer; but one woman is 50 and the other is 95. Studies comparing relative risk thus help to give a more accurate estimation of cancer’s ability to impact overall survival on average.

The SEER Cancer Statistics Review (CSR) is an annual report published by the National Cancer Institute that reports on cancer incidence, mortality, survival, prevalence, and lifetime risk statistics.

When it comes to survival rates from the SEER CSR, the data in the report only compares information from the previous 5 years. These rates may not reflect the current survival rate since treatments are improving every year and guidelines are constantly changing.

Current data on survival rates range from 2008-2014. The 5-year survival rates for individuals with breast cancer for this time period are as follows:  

  • Stage 0-1: 98.7% 5-year survival rate (4)

  • Stage 2-3: 85.3% 5-year survival rate (4)

  • Stage 4: 27% 5-year survival rate (4)

  • Overall 5-year survival rate after diagnosis with breast cancer is 89.7%

Diagnosis & Staging - What’s the Bottom Line?

Diagnosis and staging are the steps in the cancer journey that come after finding something strange in the screening phase, but directly before the treatment phase begins.

Diagnosis and staging take the mystery out of the question “Is it cancer?”

Your medical team may find it necessary to adjust screening to include watchful waiting, keeping a close watch on suspicious findings, or may recommend adjunctive screening techniques or biopsy to either confirm or rule out cancer.

This can be a scary time for people, so much so that some even avoid screening, or testing because they’re afraid of what they might find.

Understanding whether or not breast lesions are cancerous, identifying where they formed from, and how they are behaving, allows doctors to recommend treatment options that are in line with medical standards of care and help everyone on your care team to make informed decisions (including yourself).

Remember, just like we discussed in our article about screening, medical decisions are often guided by numbers and averages in general, but should always be tailored to a person’s individual case. The diagnostic phase allows your physician to better understand your body and make recommendations based on your own needs.

After finding out exactly what’s going on with a diagnosis, the next step is deciding what can be done to treat the problem. We’ll discuss common conventional breast cancer treatment options in our next article.

 
 Written by Adam Kozin. ND.

Written by Adam Kozin. ND.

(Our blog isn't designed to provide specific medical advice or replace a medical professional.  If you have any specific questions about your health, how to make changes responsibly, or would like to set up an appointment with our clinic, head to our Contact Us page and let us know)!

References

Barlow, W. E., Lehman, C. D., Zheng, Y., Ballard-Barbash, R., Yankaskas, B. C., Cutter, G. R., … Taplin, S. H. (2002). Performance of diagnostic mammography for women with signs or symptoms of breast cancer. Journal of the National Cancer Institute, 94(15), 1151–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12165640

Loughran, C. F., & Keeling, C. R. (2011). Seeding of tumour cells following breast biopsy: a literature review. The British Journal of Radiology, 84(1006), 869–74. https://doi.org/10.1259/bjr/77245199

Li CI, Uribe DJ, Daling JR. Clinical characteristics of different histologic types of breast cancer. Br J Cancer 2005; 93:1046.

Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2015, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2015/, based on November 2017 SEER data submission, posted to the SEER web site, April 2018.

https://seer.cancer.gov/statfacts/html/breast.html